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Assessment and Treatment of
Spasticity
Cori Ponter, PT, MPT, NCSBarrow Neurological Institute3/23/19
Learner Objectives
The learner will:
• Participants will be able to identify and differentiate various assessment tools used in assessing spasticity
• Participants will be able to discuss various treatment options for patients with spasticity
2
Where do we start?
Assessment Goal-Setting Choice of Treatment
How can we make our assessments meaningful?
Ashworth/Modified Ashworth
• One of the most commonly used assessment for spasticity in the clinic
• Frequently used as the “gold-standard” to validate other spasticity measures against.
• Measure of RESISTANCE TO PASSIVE MOVEMENT 1• Is NOT a measure of spasticity, but scores may by influenced
by spasticity 2• Is performed at one speed only (one-second1), so does not
capture the “velocity-dependent” component of spasticity• Good screening tool to indicate when further assessment
needed
1. Bohannon R,, et al. Physical Therapy 1987. 67:1068-1071 2. Pandyan AD, et al. Clin Rehab 1999;13(5):373 – 383
Psychometrics – Mixed Reviews
Pandyan AD, et al. Clin Rehab 1999;13(5):373 – 383Malhotra S, et al. Clin Rehabil. 1998: 1005-1115
Author Subjects Results/FindingsSloan et al 34 hemiplegic “MAS has acceptable interrater reliability for testing of upper limb spasticity, but not
so for testing of the lower limb spasticity.”
Nuyens,et al 30 MS “AS more reliable for muscles of the ankle than for muscles of the knee, and least reliable for muscles of the hip.”
Haas, et al 30 SCI Interrater reliability varied between AS and MAS, between muscle groups (hip adductors > hip extensors/flexors > ankles plantarflexors), and between limbs. Recommended for both to be used with caution when assessing LE spasticity with SCI patients
Allison et al 30 TBI Low interrater reliability for ankle plantarflexors, and argued that there was no support for continued use of MAS to assess PFs in pts with TBI.
Gregson, et al 32 acute CVA Intra/inter-rater reliability found to be “good to very good for the elbow, wrist and knee, but less satisfactory over the ankle.”
Blackburn et al 36 CVA Acceptable intra-rater reliability, but poor inter-rater reliability for MAS. Most agreement was with scores of “0,” so conclusion was that reliable measurements could be obtained to determine whether normal or low muscle tone is present or not.
Ashworth/Modified Ashworth
Bohannon R,, et al. Physical Therapy 1987. 67:1068-1071
0 No increase in tone
1 Slightly increased tone, with a catch & release or minimal resistance at terminal ROM
1+ Slight increase, catch followed by minimal resistance throughout the remainder of the range (<1/2 of the ROM) (only in MAS)
2 Marked increase through most of the ROM, but affect part is easily moved
3 Considerable increase, passive ROM difficult4 Affected part is rigid
Passive movements of muscle groups should be performed over a one-second time frame
“The results...are clear and tell us the Ashworth Scale has insufficient validity and reliability to be used as a measure of spasticity. However, we are left with the problem of how to measure spasticity in a valid and reliable way. The quest for this holy grail is ongoing.”
- Katharina S Sunnerhagen
Sunnerhagen, K. Stop Using the Ashworth scale for the assessment of spastisity [letter]. J Neurol Neurosurg Psychiatry 2010. 81:2
Slow down!
• MAS performed as a 1-second movement – which is not as fast as many of us learned in school
• The score is based on the resistance felt during that one second of passive movement
• Should be done 1-3 times at most
MAS
36 y/o male with R CVA, resulting in spastic left hemiparesis. Below are the MAS scores for his L UE and LE.
UE Muscle Group MAS LE Muscle Group MASShoulder Flexors 0 Hip Flexors 0Shoulder Extensors 2 Hip Extensors 3Shoulder Adductors 3 Hip Adductors 3Elbow Flexors 2 Hip Int Rotators 0Elbow Extensors 0 Hip Ext Rotators 2Wrist Flexors 3 Knee Extensors 0Wrist Extensors 0 Knee Flexors 2Finger Flexors 3 Ankle Plantarflexors 3Thumb Adductors 0 Ankle Inverters 0
Ankle Everters 0
Case Example
So how do we assess further??
Gracies JM, et al. Arch Phys Med Rehabil 2010;91:421-8.
The Tardieu Scale
Measures two aspects of spasticity1) Quantity -- Spasticity Angle2) Quality - Spasticity Grade
May be more useful in terms of predicting the functional implications of the spasticity, as well as
assessing the effects of treatment
The Tardieu Scale
Spasticity Angle
Gracies JM, et al. Arch Phys Med Rehabil 2010;91:421-8.
Range of motion measured at two different velocitiesV1 – Slow as possible (R2)V3 – Fast as possible (R1)
R2 R1 Spasticity Angle
Large spasticity angles indicate a large dynamic component (spasticity), whereas small differences indicate predominantly muscle contracture
Spasticity Grade
Gracies JM, et al. Arch Phys Med Rehabil 2010;91:421-8.
0 No resistance throughout passive movement
1 Slight resistance throughout passive movement
2 Clear catch at precise angle, interrupting passive movement, followed by release
3 Fatigable clonus (<10 s when maintaining pressure) occurring at a precise angle, followed by release
4 Unfatigable clonus (>10s when maintaining pressure) occuring at a precise angle
Notes: If spasticity angle = 0, grade must be a 0 or 1 by definitionIf spasticity angle > 0, grade must be at least a 2, even if no
definite “release” felt
What does the literature say?
More likely to identify presence of spasticity [but not severity] and the presence of contractures than MAS/AS1
Very good intra-rater reliablity across 2 sessions in elbow flexors and ankle plantarflexors 2
Good reliability in assessing elbow flexor and ankle plantarflexor spasticity 3
Reliability significantly increases with training3
“In patients with severe brain injury and impaired consciousness the Modified Tardieu Scale provides higher test retest and inter-rater reliability compared with the Modified Ashworth Scale and may therefore be a more valid spasticity scale in adults.” 4
See additional references
How to perform the Tardieu Scale
Gracies JM, et al. Arch Phys Med Rehabil 2010;91:421-8.
• Measure R2 – Achieved with a SLOW and powerful passive movement (V1). This should give us the full range of motion of the muscle group. • Should be slow enough to prevent eliciting any
stretch reflexes• Should be powerful enough to overcome any
resting dystonia• R2 is documented as the point where no further
passive movement is achievable.
• Measure R1 – Achieved with a passive movement that is as fast as possible (V2)• R1 is documented as the angle at which the first
resistance is felt
• Calculate Spasticity angle – the difference between the two angles of R2 and R1
• Assign Spasticity Grade to the resistance felt during R1 measurement
How to perform the Tardieu Scale
Case Example, cont
UE Muscle Group MAS R2 R1 Spasticity > Prob ImplicationShoulder Extensors 2 180 40 140 Spasticity
Shoulder Adductors 3 120 120 0 M TightnessElbow Flexors 2 150 120 30 M Tightness
SpasticityWrist Flexors 3 100 80 20 M Tightness
SpasticityFinger Flexors 3 150 150 0 M TightnessHip Extensors 3 100 100 0 Tightness (M, C?)Hip Adductors 3 120 110 10 M Tightness
Hip Ext Rotators 2 110 110 0 CapsularKnee Flexors 2 180 60 120 SpasticityAnkle Plantarflexors 3 70 70 0 M Tightness
Assessing the spasticity angle
Active Range of Motion
• NOT a measure of strength, but a measure of how much the spastic muscle can be overcome!
• Documented as the number of degrees of active movement.
• Are we seeing co-contraction of the antagonist?
Gracies JM, et al. Arch Phys Med Rehabil 2010;91:421-8.
Rapid Alternating Contractions
• Looking at the time it takes to perform a set number of active movements (into their full AROM)
• Co-contraction usually increases with effort and fatigue
• May be more indicative of what we see in functional mobility (ie, gait, feeding).
Gracies JM, et al. Arch Phys Med Rehabil 2010;91:421-8.
Modified Frenchay Scale
Modified Frenchay Scale
0 = not able to perform any of task/no mvmt5 = barely accomplished task10 = normal performance
High intra- and inter-raterreliability (Baude et al. ESNR,2015)
Gracies,Handbook of botulinum toxin 2002; 2009; 2015
FUNCTION!!!
Severity Significance
Functional Assessment
1. Gracies JM, et al. Arch Phys Med Rehabil 2010;91:421-82. Doan, et al. PMR 2012 Jan; 4(1):4-10 (abstract)
ASK QUESTIONS!How is this impacting their lives? Severity ≠ Significance!What are THEIR goals of treatment?
OBSERVE!Watch them walk, transfer, maneuver w/c, eat, dress, etcHow are they positioned?VIDEO, VIDEO, VIDEO!
BE OBJECTIVEUse measures such as 10-meter walk, 6-minute walk test,
Gaitrite, Goal Attainment Scale
Pre-trial gait
Post-trial gait
Handwriting
Setting goals
Assessment Goal-Setting Choice of Treatment
Who are we focused on when setting goals?
Clinician Goals
Patient Goals
Goal check
Meaningful Realistic/Achievable
Functional Objective
Patient-centered
Treatment options
Assessment Goal-Setting Choice of Treatment
Interdisciplinary Treatment
Patient & Family
Pharmacist
Physical Therapy
Occupational TherapyPhysician
Social Work/Case
Management
Nursing
ITB patient education
The pre and post trial process Implant process
What we are looking for during
the post-trial assessment
Pump precautionsWhat a pump may
or may not help with
Possibility of initial functional decline• Necessity for further
therapy
Potential for weight gain
Importance of refills
Signs of withdrawal!!!• Itcy, witchy, twitchy
Graham, L. Oxford Journals, 2013 (42)435-441
Therapy management
Therapy-driven neuroplasticity?
• 23 patients at least 6 months post-CVA– Documented spasticity and at least trace activation in
selected UE muscle groups• Outcome measures – MAS, FM, sensory tests, fMRI• Intervention – 12 week motor learning therapy program,
including treatment for spasticity• Results
– Greater spasticity correlated with poorer function according to FM scores, and with greater severe sensory deficits
– Significant gains in motor function measured with FM total score
– Improvements in spasticity correlated with increased task-related brain activation in the CONTRAlesional M1, LPM, S1 and AS regions
Pundik, et al. Stroke Research and Treatment (2014); 306325
BWSTT vs Tilt Table in SCI
When body weight supported treadmill training and tilt table programs were compared in patients with SCI -
– BWSTT had greater decreases in flexorspasms, clonus, and self-reported mobility after 4 weeks of treatment
– Tilt table standing had greater reduction in extensor spasms after 4 weeks of treatment.
– Participants in BWSTT appeared to have higher scores on QoL measures
Adams, M and Hicks A. The Journal of Spinal Cord Medicine; 2011 (31) 488-494
Casting
• A conservative and effective modality to reduce muscle tightness, decrease chance of deformity, and achieve optimum alignment of a joint.
• Casts offer a temporary, specific, and noninvasive intervention as an alternative or complement to other interventions.
• Casting may help eliminate, delay, or minimize the need for surgical interventions.
• Best outcomes combined with medical management
Park E, et al. Yonsei Medical Journal. 2010; 51(4): 579-584Verplancke D, et al. Clinical Rehabilitation. 2005. 19(2): 117-125
Alternatives
Positioning
Positioning
Modalities
• Heat and Cold– Temporarily decreases tone and increases pain
thresholds– May be beneficial in conjunction with
strengthening antagonistic muscles or prior to casting
• Vibration– Shown to have short term decreases in tone as
well as improvement in function– Should be used in conjuction with other
therapies
Smania, N, et al. Eur J Phys Rehabil Med 2010; 46:423-38
50
Estim leading to muscle contraction:
Pure sensory stimulation thought to inhibit overactivity through influencing the excitability of the alpha motor neurons and triggering sensorimotor reorganization
Stimulation of the overactive muscles may lead to fatigue, thus decreasing activation
Minimal results published regarding long-term effects, but has been shown to have good short term effects
Increases in function are thought to be a result of increasedmotor control gained during brief inhibitory period following e-stim
Modalities
Smania, N, et al. Eur J Phys Rehabil Med 2010; 46:423-38
51
Strengthening
Smania, N, et al. Eur J Phys Rehabil Med 2010; 46:423-38
• Research shows us that spastic muscles are weak muscles• Strengthening (post-CVA) has been shown to
• Increase function• Decreased perceived limitations & increase perceived QOL• Increase gait speed• Has not been shown to increase spasticity (as measured by
Pendulum test or MAS)
Does strengthening a spastic muscle
increase the over-activity?
Historical thought
was…YES
Research says…..NO
The dreaded PLATEAU
Who is plateauing? The patient?The therapist?The physician?
Can we change the recovery trajectory for the patient?
Is one year all we get?
Self-Guided Contract
• Retrospective study by Pradines, et al in 2015 • 30 subjects (all > 1 yr post lesion) all followed
self-guided contract– Antagonist-based– Diary-based
• Alternating stretching and rapid maximal amplitude alternating movements (eccentric stretches), documented in daily diary, performed for at least 1 year
Responder rate
Gait speed
Optimizing Outcomes
Medical management
Therapy interventions
Better outcomes!
Pre and post Botox
Pre and post Botox
66
OutcomeTeam approach to spasticity management
• 37-yo male who suffered a severe traumatic brain injury from an assault two years earlier
• Completed one month of inpatient rehabilitation
• Was sent home just as he was emerging from a coma
67
OutcomeTeam approach to spasticity management
• Home therapy cannot do much because of posture
• Drugs and injections to treat muscle tightness did not work
• Surgery?
68
OutcomeTeam approach to spasticity management
Before Any Therapy Can be Done:• INFECTIOUS DISEASES CONSULTATION
• Antibiotics for groin abscess• ORTHOPEDICS
• Hip contracture release• Groin abscess I&D
• NEUROSURGERY• Intrathecal Baclofen therapy
69
OutcomeTeam approach to spasticity management
Before After Surgeries
70
OutcomeTeam approach to spasticity management
• Inpatient rehabilitation• PHYSICAL AND
OCCUPATIONAL THERAPY
• Botulinum toxin injections to neck• SPEECH THERAPY
• Improved speech and swallowing
71
OutcomeTeam approach to spasticity management
• ORTHOPEDIC SURGEON• Knee flexion
contracture• Repeat botulinum
toxin injections to wrists and neck
• More therapies
Botox™ 200 units :
Finger flexors (FDS, FDP)Long thumb flexor (FPL)
67/male, 3 years post TBI, Anoxia, Stroke
Botox™ 200-250 units :
Finger flexors (FDS, FDP)MCP flexor (lumbricals)FPL
Occupational therapy:
Stretch/weight-bearingSerial casting“Forced-use”
Questions???
Additional References
1. Patrick E, Ada L. The Tardieu Scale differentiates contracture from spasticity whereas the Ashworth Scale is confounded by it. Clinical Rehabilitation. 2006;20(2):173–181.
2. Singh P, Joshua A, Ganeshan S, Suresh S. Intra-rater reliability of the modified Tardieu scale to quantify spasticity in elbow flexors and ankle plantarflexors in adult stroke subjects. Annals of Indian Academy of Neurology 2011. 14(1): 23-36
3. Gracies JM, Burke K, Clegg NJ, Browne R, Rushing C, Fehlings D et al. Reliability of the Tardieu Scale for assessing spasticity in children with cerebral palsy. Arch Phys Med Rehabil2010;91:421-8.
4. Mehrholz J, Wagner K, Meissner D, Grundmann K, Zange C, Koch R, Pohl M. Reliability of the Modified Tardieu Scale and the Modified Ashworth Scale in adult patients with severe brain injury: a comparison study. Clin Rehabil. 2005. 19(7): 751-759
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TIRR Memorial Hermann Entities
Memorial Hermann Rehabilitation Network Entities